A Dissertation on
“A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER
SUB ARACHNOID BLOCK ”
submitted to
THE TAMILNADU DR M.G.R.MEDICAL UNIVERSITY in partial fulfilment for the award of the degree of
DOCTOR OF MEDICINE IN
ANAESTHESIOLOGY BRANCH X
DEPARTMENT OF ANAESTHESIOLOGY
& CRITICAL CARE
STANLEY MEDICAL COLLEGE CHENNAI-600 001
APRIL 2016
DECLARATION BY THE CANDIDATE
I hereby declare that the dissertation entitled “
A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER SUB ARACHNOID BLOCK” has been prepared by me under the Guidance of Prof.
Dr KUMUDHA LINGARAJ, M.D., D.A., Professor of Anaesthesiology, Department of Anaesthesiology, Stanley Medical College, Chennai, in partial fulfilment of the regulations for the award of the degree of M.D(ANAESTHESIOLOGY), examination to be held in April 2016.
This study was conducted at Department Of Anaesthesiology, Stanley Medical College, Chennai.
I have not submitted this dissertation previously to any university for the award of any degree or diploma.
Date :
Place : Chennai DR. KOUSALYA. T
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled, “
A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER SUB ARACHNOID BLOCK” submitted by Dr. KOUSALYA.T, under the guidance of Prof. Dr KUMUDHA LINGARAJ, M.D., D.A., in partial fulfilment for the award of the degree of Doctor of Medicine in Anaesthesiology by The Tamilnadu Dr.M.G.R.Medical university , Chennai is a bonafide record of the work done by her in the DEPARTMENT OF ANAESTHESIOLOGY &
CRITICAL CARE, Stanley Medical College, during the academic year 2013- 2016.
Prof. Dr KUMUDHA LINGARAJ, M.D., D.A.,
Prof and Guide, Department of Anaesthesiology and critical care, Stanley Medical College,
Chennai-600 001.
CERTIFICATE BY THE HOD
This is to certify that the dissertation entitled, “
A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER SUB ARACHNOID BLOCK” submitted by Dr.KOUSALYA.T, under the guidance of Prof. Dr KUMUDHA LINGARAJ, M.D., D.A., in partial fulfilment for the award of the degree of Doctor of Medicine in Anaesthesiology by The Tamilnadu Dr.M.G.R. Medical university , Chennai is a bonafide record of the work done by her in the DEPARTMENT OF ANAESTHESIOLOGY &
CRITICAL CARE, Stanley Medical College, during the academic year 2013- 2016.
DR.N.LATHA.M.D.,D.A., Prof and HOD,
Department of Anaesthesiology & critical care, Stanley Medical College,
Chennai-600 001.
ENDORSEMENT BY THE DEAN
This is to certify that the dissertation entitled, “
A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER SUB ARACHNOID BLOCK” submitted by Dr.KOUSALYA.T, under the guidance of Prof. Dr KUMUDHA LINGARAJ, M.D., D.A., in partial fulfilment for the award of the degree of Doctor of Medicine in Anaesthesiology by The Tamilnadu Dr.M.G.R. Medical university, Chennai is a bonafide record of the work done by her in the DEPARTMENT OF ANAESTHESIOLOGY &
CRITICAL CARE, Stanley Medical College, during the academic year 2013- 2016.
DR.ISAAC CHRISTIAN MOSES. M.D., FICP, FACP DEAN,
STANLEY MEDICAL COLLEGE,
CHENNAI-600 001.
ACKNOWLEDGEMENTS
I wish to express my sincere thanks to DR.ISAAC CHRISTIAN MOSES. M.D., FICP, FACP. Dean, Government Stanley Medical College and Hospital for having permitted me to utilize the facilities of the hospital for the conduct of the study.
My heartfelt gratitude to Prof. Dr. N . LATHA M.D., D.A., Professor and Head, Department of Anaesthesiology, Government Stanley Medical College and Hospital for her motivation, valuable suggestions, expert supervision, guidance and for making all necessary arrangements for conducting this study.
I thank Prof. Dr KUMUDHA LINGARAJ, M.D., D.A., for her constant motivation and support apart from providing immense help and valuable suggestions in carrying out this study. His continuous support and ideas are the key factors for the construction of the study.
I thank Prof Dr. S. PONNAMBALA NAMASIVAYAM M.D.,D.A.,D.N.B, for his constant motivation, guidance and valuable suggestions in carrying out this study.
I thank Prof. Dr. DHANASEKARAN, M.D., D.A., for his constant
support and encouragement throughout the study.
I thank Prof Dr. S. KRISHNA KUMAR M.D. Professor, Department of Anaesthesiology, Government Stanley Medical College and Hospital for his motivation, constant encouragement and support.
I express my heartfelt gratitude to Assistant Professors Dr.
M.K.NARASIMHAN MD
who had evinced constant and keen interest in the progress of my study right from the inception till the very end and was instrumental in the successful completion of the study.
I wish to thank all Assistant Professors especially for their aid and encouragement during the study.
I thank Mr. VENKATESAN, for helping me in statistical analysis.
My sincere thanks to all those post graduates who helped me during this study period.
I thank the staff nurses and theatre personnel, Government Stanley Medical Hospital for their cooperation and assistance.
I owe my gratitude to all the patients included in the study and their
relatives, for their whole hearted co-operation and consent.
1. Introduction 1
2. Aim of the Study 3
3. Epidural Anatomy & techniques 5
4. Ultrasonogram 14
5. Fascia iliaca compartment block – Clinical Anatomy & Techniques
25
6. Bupivacaine Pharmacology 36
7. Materials And Methods 41
8. Review of Literature 51
9. Observations and Results 58
10. Discussion 77
11. Conclusion 86
12. Bibiliography 87
13. Annexure
a. Ethical Committee
b. Antiplagrism Screen Shot c. Patient Information Form d. Patient Consent Form e. Proforma
f. Master Chart
LIST OF TABLES
S.No Title Page no
1 Criteria for positive Epinephrine test 11 2 Imaging of various structures 24
3 Age distribution 59
4 Sex distribution 60
5 Weight Distribution 61
6 Height Distribution 62
7 Distribution of Procedure 63
8 ASA classification 64
9 Distribution of duration of surgery 65 10 Distribution of VAS score 66 11 Distribution of Mean heart rate 67 12 Distribution of systolic blood pressure 69 13 Distribution of diastolic blood pressure 70 14 Mean arterial pressure 71
15 PONV score 72
16 Rescue analgesic requirement 73 17 Incidence of urinary retention 74
18 Patient satisfaction 75 19 Therapeutic failure 76
LIST OF FIGURES
S.No Title Page no
1 Epidural space anatomy 6
2 Midline approach 9
3 Sector FOV 19
4 Linear FOV 20
5 Curvilinear, low frequency probe 22 6 Linear high frequency probe 22 7 Anatomy of Lumbar plexus 25 8 Sensory innervation of lower limb 26 9 Motor innervation of lower limb 26 10 Fascia iliaca compartment 29 11 Sonoanatomy of Fascia iliaca Block 30 12 Landmarks of Fascia Iliaca block 33 13 Landmark technique of fascia iliaca block 33 14 Fascia iliaca compartment block (needle in situ) 35 15 Chemical structure of Bupivacine 36
S.no Title Page No 16 Visual analogue score 47
17 Age distribution 59
18 Sex distribution 60
19 Weight Distribution 61
20 Height Distribution 62
21 Distribution of Procedure 63
22 ASA classification 64
23 Distribution of duration of surgery 65 24 Distribution of VAS score 67 25 Distribution of Mean heart rate 68 26 Distribution of systolic blood pressure 69 27 Distribution of diastolic blood pressure 70 28 Mean arterial pressure 71
29 PONV Score 72
30 Rescue analgesic requirement 73 31 Incidence of urinary retention 74
32 Patient satisfaction 75
33 Therapeutic failure 76
A RANDOMISED CONTROLLED STUDY COMPARING THE ANALGESIC EFFICACY OF EPIDURAL ANALGESIA WITH USG GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR FEMUR SURGERY DONE UNDER
SUB ARACHNOID BLOCK
Authors: Dr. T.Kousalya, Dr. Kumudha Lingaraj, Dr. M.K.Narasimhan
Background
: Peroperative analgesia in surgeries involving femur fractures has been a challenge to the Anaesthesiologist since ages. Perineural analgesia is becoming popular as it provides comparable pain relief and decreases the side effects associated with central neuraxial blockade. We decided to compare the analgesic efficacy of ultrasound guided fascia iliaca compartment block with epidural block forpostoperative pain relief in patients undergoing femur surgery under sub arachnoid block.
Aim
: To compare the analgesic efficacy of Continuous Epidural block with Continuous Fascia Iliaca Compartment Block for femur surgery done under subarachnoid block.Methods
: A total of 120 ( n=120 ) consented patients fulfiling the inclusion criteria who underwent elective surgery for fracture femur were selected. They were randomized to group F ( n = 60 ) and group E ( n = 60 ) to receive either Fascia iliaca compartment block or Epidural block respectively for postoperative analgesia. The technique of spinal anaesthesia were standardised in both the groups. Group E patients received epidural catheter at the time of spinal anaesthesia preoperatively . Group F patients received fascia iliaca catheter at the end of procedure. 20 ml of 0.125%bupivacaine injected via the catheter in the group F patients. In the recovery room both Group F and Group E were started with continuous infusion of 0.125%
bupivacaine via catheter at the rate of 8ml/hr for 24 hours .
Results
: There was no substantial demographic difference between both the groups.The mean VAS score in both the groups were comparable.. The other hemodynamic parameters and side effects were comparable between both the groups.
Conclusion
: We arrived at a conclusion that the FICB holds considerable promise as an effective postoperative analgesia with less side effects compared to Epiduralanalgesia.
Keywords
: Epidural analgesia, Fascia iliaca compartment block, bupivacaine, postoperative analgesia.INTRODUCTION
Femur fractures cause moderate to severe pain which requires effective analgesia both preoperatively and postoperatively1. Multimodal analgesic regimens which include Non steroidal anti-inflammatory drugs, opioids &
various regional analgesic techniques have been used in femur surgeries so far.
NSAIDs even in moderate dose cause adverse effects, especially in the elderly population2. Although opioids are potent analgesics, they are associated with serious adverse effects like drowsiness, nausea, respiratory depression, constipation etc. limiting their use3.
Epidural analgesia is considered by many as the gold standard analgesic technique for femur surgeries4. Apart from effective analgesia it decreases the neuro-endocrine stress response, central sensitization & muscle spasm that occur in response to painful stimuli5. There is a substantial evidence showing reduced blood loss and fewer thromboembolic complications following neuraxial blockade6,7,8.
However Lumbar epidural analgesia is also commonly associated with various problems like hypotension, urinary retention, undesired bilateral sensory and motor blockade and delay in mobilization.
Perineural analgesia is becoming popular as it provides comparable pain relief and decreases the side effects associated with central neuraxial
blockade9. Peripheral nerve blockade was initially done with either paresthesia technique or nerve stimulation based technique. Ultrasound guided needle &
catheter placement is observed to be technically superior, more accurate, being placed in peripheral location probably increases the safety of such techniques compared with others.
Fascia iliaca compartment block was initially described by Dalens et al10 on children using landmark technique. It is relatively simple, easier to perform, and provides perioperative analgesia in patients with painful conditions affecting the thigh, hip joint and femur. The use of ultrasound to aid identification of the fascial planes may lead to faster onset and dense motor blockade. This increases the rate of successful blocks11.
Taking all these into consideration, we decided to conduct a prospective randomized controlled study at Government Stanley Medical College hospital, comparing the analgesic efficacy of ultrasound guided fascia iliaca compartment block with epidural block for postoperative pain relief in patients undergoing femur surgery under subarachnoid block.
AIM OF THE STUDY
To compare the analgesic efficacy of Continuous Epidural block with Continuous Fascia Iliaca Compartment Block for femur surgery done under subarachnoid block.
OBJECTIVES
Primary outcome measures:
Assessment of the postoperative pain by Visual Analogue scale
Secondary outcome measures:
a. Postoperative Nausea and vomiting b. Rescue Analgesic requirement c. Patient satisfaction
d. Therapeutic / technical failure rate e. Complications
EPIDURAL ANATOMY AND TECHNIQUES
Anatomy12,13
It is a potential space that lies between the dura and the periosteum lining the vertebral canal. It extends from the foramen magnum to the sacral hiatus. The anterior and posterior nerve roots with their dural covering pass across this potential space to unite in the intervertebral foramen to form segmental nerves. The space contains venous plexuses and fatty tissue, which is continuous with the fat in the paravertebral space.
Boundaries14
i. The anterior border consists of the posterior longitudinal ligament covering the vertebral bodies and the intervertebral discs.
ii. Laterally, the epidural space is bordered by the periosteum of the vertebral pedicles and the intervertebral foraminae.
iii. Posteriorly, the bordering structures are the periosteum of the anterior surface of the laminae and articular processes and their connecting ligaments, the root of the spines.
Figure 1. Epidural Space Anatomy
EPIDURAL ANESTHESIA15 Introduction
The epidural space was first described by Corning in 1904. Fidel Pages first used epidural anaesthesia in humans in 1921. In 1945, Tuohy introduced the needle which is called as Tuohy epidural needle.
Indications
(i) Sole anaesthesia for the lower limbs, pelvis, perineum and lower abdomen surgeries.
(ii) Upper abdominal and thoracic surgeries under thoracic epidural anaesthesia
(iii) Postoperative analgesia Contraindications16
Absolute Contraindications
Patient refusal
Coagulopathy
Severe hypovolemia
Bleeding disorders
Raised intracranial pressure.
Relative Contraindications
Uncooperative patients
Patient with progressive neurological disorders
Infection at the site of injection
Fixed cardiac output states like aortic stenosis, Hypertrophic obstructive cardiomyopathy (HOCM), Mitral stenosis and complete heart block.
Anatomical abnormalities of vertebral column
Prophylactic low dose heparin
Technique of Epidural Anaesthesia
Preparation
1. Obtain informed consent.
2. Pre-anaesthetic assessment
3. An epidural must be performed in a work area that is equipped for airway management and resuscitation.
4. Facilities for monitoring
5. Performed with aseptic precautions
Equipment
The epidural needle called Tuohy needle is 16-18G, 8cm long with surface markings at 1cm intervals, and has a blunt bevel with a 15-30 degree curve at the tip that is Huber tip. Epidural catheters have either a single end-hole or a number of side holes at the distal end. A needle hub insert to be used to thread the catheter. A reinforced catheters are available to prevent buckling
Glass syringe with plunger or plastic syringe to identify epidural space by means of loss of resistance or hanging drop technique.
Test dose in 5ml syringe
Povidone solution with sponge holder
Strerile drapes, gauzes, and adhesive tapes
TECHNIQUES OF EPIDURAL BLOCKADE
Midline Approach17:
Patient is placed in the lateral position. Under aseptic precaution, skin is infiltrated with local anaesthetic solution upto the interspinous ligament.
18 Gauge Tuohy epidural needle is inserted in the midline. Testing syringe is attached to the needle. After piercing through the supraspinous, interspinous, ligamentum flavum, the epidural space is identified by “loss of resistance technique” to air19. Then a gentle aspiration is done and test dose of 3 ml of 2
% lignocaine with 1:200000 of Adrenaline is injected. 19 Gauge multi port catheter is inserted and fixed at the depth of 5 cm within the epidural space
Figure 2 Midline Approach
Paramedian Approach
Insert needle 1-2cm lateral to the spinous process of vertebra.
Advance the needle, perpendicular to the skin until the lamina or pedicle is encountered
Redirect it approximately 30° cephalad and 15° medially in an attempt to "walk the needle" off the lamina
This method bypasses supraspinous and interspinous ligaments.
Test dose20
Ideal test dose contains 15mcg of 1:200,000 adrenaline and 3ml of LA
It should identify both intravascular and intrathecal placement
Effective doses of o Lignocaine- 45mg o Bupivacaine- 15mg o Ropivacaine- 16mg
Criteria for positive epinephrine test (ASRA 2001)
Table 1. Criteria for Positive Epinephrine Test Patient <60 years not on beta
blockers
HR increase > 20 bpm SBP increase > 15 mmHg Patient < 60 years on beta blockers SBP increase >15 mmHg
Age > 60 years HR increase > 9 bpm SBP increase >15 mmHg
Under GA HR increase >8 bpm
SBP increase > 13 mmHg
Intrathecal placement can be identified by the presence of motor blockade of great toe.
Volume21 :
Volume of LA solution injected per number of dermatomes blocked and for each pair of segments the recommendations are
Cervical- 1.5ml
Thoracic- 2ml
Lumbar- 2.5ml
For single injection technique 15 to 20 ml of LA solution is recommended.
For continuous technique initial bolus volume of 8 to 12 ml followed by 5 to 7 ml every hour.
Site of Action
Three sites
On the nerves as they transverse epidural space
On the nerves in the intervertebral foramina
On the nerves in the subarachanoid space after diffusion through the dura
The main site of action is considered to be on the nerves in the intervertebral foramina
Physiological Effects18
The segmental nerves in the thoracic and lumbar region contain somatic sensory, motor and autonomic (sympathetic) nerve fibers.
Sensory and autonomic fibers have a smaller diameter and are more easily blocked than larger, more rapidly-conducting motor fibers.
Sympathetic block usually extends 1-2 levels higher than sensory block.
Sensory block extends 2 levels higher than the motor block
Vasodilatation of resistance and capacitance vessels occur, with a resultant drop in blood pressure.
Exacerbated by blockade of the sympathetic nerve supply to the adrenal glands, preventing the release of catecholamines.
If blockade is as high as T2, sympathetic supply to the heart (T2-5) is also interrupted and may lead to bradycardia.
Overall result may be inadequate perfusion of vital organs and measures are required to restore the blood pressure and cardiac output, such as fluid administration and the use of vasoconstrictors.
Sympathetic outflow extends from T1 - L2 and blockade of nerve roots below this level, is less likely to cause significant sympathetic blockade
Complications:
The complications can be
Technical related
Catheter related
Clinical complications Technique Related
Inadvertent dural puncture
Subdural Injection
Vascular injury on catheter insertion Catheter Related:
Migration of catheters
Extrusion of catheters
Paresthesia on insertion of catheter
Clinical Complications
Hypotension
Local anesthetic toxicity, reactions
Neurologic sequelae
Failure of block
Miscellaneous-Epidural Hematoma, Epidural abscess, backache
ULTRASONOGRAM
Ultrasound usage in regional anesthesia is relatively new, however interest in this application is growing rapidly. It has advantages of
i. Visualizing the nerve location and the surrounding vascular, bony, muscular, and visceral structures. Provides real-time imaging guidance during needle advancement allowing for proper needle movement and adjustments in direction and depth.
ii. Images the local anesthetic spread pattern during injection. Improves the quality of sensory block, the onset time, and the success rate compared to nerve stimulator techniques
iii. Reduces the number of needle attempts for nerve localization which may prove to reduce the risk of nerve injury. Eliminate intraneural and intravascular injections.
Principles
Ultrasound is sound wave with frequency above the audible range.
Frequencies used in clinical imaging are in the range of 1 to 20 MHz.
Ultrasound waves have velocity of 1540 ms in soft tissues.
Piezoelectric Effect
Ultrasound imaging is based on the transmission and reflection of longitudinal high frequency ultrasonic waves. The production of ultra sonic waves from transducers when a voltage is applied works on the principle of piezoeletctric effect.
The ultra-sonogram transducer converts one type of energy into another.
When the transducer converts electrical energy into extremely rapid mechanical vibration that are very high sounds to hear. The electrical field required is formed when a voltage is applied between the surfaces of 2 electrodes. This causes a dimensional change in the crystals. Conversely when the mechanical vibrations from the tissues is reflected back to the transducer they compress the crystals and generate an electrical potential. This is defined as the pulse echo principle.
Based on the pulse echo principle transducers convert, Electrical into mechanical (sound) = pulse
Mechanical (sound) into electrical potential = echo.
Pulse
Pulse is the wave that is sent to the soft tissues. Bio-effect is the interaction of pulse wave with soft tissue. Pulsing is determined by transducer or probe crystal.
Echo
The wave produced by the soft tissue is called the echo. The echoes are received back by the transducer crystal. The ultra-sonogram machine interprets and processes these images.
Frequency
The number of cycles completed per unit time. Transducer frequencies are as follows
2.5 to 3.5 MHz = Abdomen, Obstetrics and gynaecology
5 to 7.5 MHZ = Breast, thyroid
7.5 to 10 MHz = Superficial structures.
Wavelength
It is the distance between consecutive cycles of sound. A range of frequencies is known as bandwidth.
Anisotropy in nerve imaging
Anisotropy is a major property of ultrasound imaging. This describes the different echogenicity of soft tissues such as nerves and tendons, when the angle of the transducer is altered. Nerve fibers look hyper echoic (bright) when the transducer is perpendicular. But can appear hypoechoic if the transducer is angled obliquely.
Image Resolution
The main aim of the ultrasound technique after image formation is good resolution. This resolution includes axial/lateral resolution, contrast of the image, spatial and temporal resolution.
Spatial compound imaging
Spatial compound imaging combines multiple lines of insonation within a planar scan to produce a single image. It defines clearly the nerve borders and tissue planes. It also improves the visibility of the needle tip over a limited range of needle angles.
Machine components 1) Transducer Types
a) Mechanical i) Oscillating ii) Rotating.
b) Electronic.
i) Linear arrays ii) Curved arrays iii) Phase arrays 2) Receiver
3) Memory 4) Display
Figure 3 esovite ultrasonagram
Field of View
Sector FOV: Produced by oscillating/rotating curved arrays, phased arrays. Sector FOV is used in cardiac and abdominal applications.
Linear FOV: Produced by linear arrays. Linear FOV is commonly used in superficial applications.
Figure 4 Sector FOV
Figure 5 Linear FOV
Ultrasound transducers and manipulation
Ultrasound transducers with high frequency broadband linear probe producing linear arrays have proven to be most useful for nerve imaging.
Images from linear arrays are displayed in a rectangular format. One of the essential skills to acquire for USG guided regional nerve blocks is transducer manipulation.
Manipulations are
1. Sliding (moving contact) – Sliding the transducer along the nerve course using a short axis view often helps with nerve identification.
2. Tilting (cross plane, side to side) – The echo brightness of peripheral nerves varies with a degree of tilt. Optimizing this angle is critical to promote nerve visibility.
3. Compression: Compression is often used to confirm venous structures.
To improve imaging, compression not only provides better contact but also brings the structures closer to the surface of the transducer.
4. Rocking (in-plane, towards/away from the indicator) – Rocking is often used to improve needle and anatomy structures.
5. Rotation: Some rotation of the probe will produce true short axis views rather than oblique or long axis views.
Probe Types:
Figure 6. Curvilinear, low frequency probe:
Figure 7: Linear High Frequency Probe22
Display Modes
First imaging modality used with USG was A mode (amplitude). Today most of the imaging is with B mode (brightness). It is a 2 dimensional image.
M Mode (motion) – This mode records echo’s from the heart. This could be interpreted in terms of myocardial and valvular function.
Doppler – The frequency shift in echo is measured after a certain time.
Colour Doppler – Uses colour corresponding to frequency shift. Red is for near to and blue for away from the probe.
Nerve Imaging with ultrasound23
Fascicles of peripheral nerves can be detected with high resolution ultrasound imaging. This fascicular echo texture also known as honeycomb architecture is the most distinguishing feature of nerves. High ultrasound frequencies around 10 MHz are required to distinguish nerves from tendons based on the echo texture alone. To identify nerve fascicles a broad linear transducer is made to slide over the known course of a peripheral nerve in short axis view. Along with nerve imaging, identification of nearby structures are also important. During local anaesthetic injection, the favorable distribution of drug and delineation of nerve can be visualized.
Table 2. Imaging of Various Structures
Block Needles for USG guided procedures23
Needle tip visibility is best when the needle path is parallel to the active phase of the transducer and is perpendicular to the sound beam, so strong specular reflections will be produced. As the angle of incidence is increased, mean brightness will decrease. Bevel orientation does influence the needle tip, with best visibility with the bevel either directly facing or averting the transducer. Because needle diameters are smaller than the scan plane, larger needles are more echogenic than smaller ones.
Tissue Ultrasound Image For Regional Anesthesia Veins anechoic (compressible)
Arteries anechoic (pulsatile)
Fat hypoechoic with irregular hyperechoic lines
Muscles heterogeneous (mixture of hyperechoic lines within a hypoechoic tissue background)
Tendons predominantly hyperechoic technical artifact (hypoechoic) Bone ++ hyperechoic lines with a hypoechoic shadow
Nerves hyperechoic / hypoechoic technical artifact (hypoechoic)
FASCIA ILIACA COMPARTMENT BLOCK
Anatomy12,13 :
Nerve supply of the lower extremity 1) Femoral nerve
2) Sciatic nerve 3) Obturator nerve
4) Lateral femoral cutaneous nerve
Femoral nerve, lateral cutaneous nerve, obturator nerve all originates from lumbar plexus. The sciatic nerve arises from lumbar as well as the sacral plexus ( lumbosacral plexus).
Figure 8: ANATOMY OF LUMBAR PLEXUS
Figure 9: Figure 10.
Sensory Innervation of Lower Limb Motor Innervation of Lower Limb
Femoral Nerve
This is the largest branch of the lumbar plexus, arises from the posterior division of the anterior rami of L2, L3, L4. It descends through the psoas major and emerges from its lateral border, continues caudally between psoas major and iliacus. Behind the inguinal ligament it enters the thigh, lying lateral to the femoral artery where it divides into anterior and posterior divisions and above the iliacus muscle. It is separated from the artery by the fascia iliaca. In the thigh cutaneous branches arises that innervate the anteromedial surface of the thigh. The saphenous nerve, branch from posterior division supplies the skin of medial aspect of the lower leg, ankle, foot and gives motor supply to knee extensors.
Obturator Nerve
Originates from anterior division of the anterior rami of L2, L3, L4. It emerges at the medial border of psoas major, enters the thigh through the obturator foramen, it divides into anterior and posterior branches. The anterior branch supplies the adductor longus, brevis, gracilis and hip joint. Posterior branch supplies obturator externus, adductor magnus, brevis and knee joint.
Accessory obturator nerve arises from L3, L4 and it is present in about 30% of cases.
Lateral Femoral Cutaneous Nerve
Originates from L2, L3 emerges from lateral border of psoas major, passing behind the inguinal ligament runs towards the anterior superior iliac
spine. Entire course covered by fascia illiaca. In the thigh it divides into terminal cutaneous branches and supplies the lateral aspect of thigh.
Sciatic Nerve
Originates from L4 to S3 via lumbosacral plexus. It supplies the flexor compartment of thigh and muscles below the knee by means of tibial and common peroneal nerves. The sensory supply follows motor supply except in the medial aspect of lower leg, which is supplied by saphenous nerve. By fascia iliaca compartment injections, it is not possible to block sciatic nerve.
Iliacus Muscle
The iliacus muscle is a large, flat, triangular muscle that lines and fills the ilium. It originates from all along the upper portions of the ilium, iliac crest, sacrum, iliolumbar ligaments. It joins with the lateral side of the psoas muscle together called as iliopsoas. The iliopsoas muscle exits the pelvis beneath the inguinal ligament, wraps around the proximal neck of femur & inserts into the lesser trochanter, acting as a powerful hip flexor.
The Fascia Iliaca 28:
Fascia iliaca lines the posterior abdomen and pelvis, from the lower thoracic vertebra to the anterior thigh. Forms the posterior wall of femoral sheath, covers psoas major and iliacus muscle in the femoral triangle covered by fascia lata. Fascia covering of the iliopsoas is thin superiorly, becoming significantly thicker as it reaches the level of inguinal ligament which is the reason for a pop up as the needle tip is passed through the fascia.
Attachments
Medial – vertebral column, pelvic brim, pectineal fascia
Lateral – thoracolumbar fascia, iliac crest, sartorious fascia, anterior superior iliac spine
Anterior – posterior part of inguinal ligament, fascia lata
Fascia Iliaca Compartment
It is a potential space with the following limits
Anteriorly - posterior surface of the fascia iliaca
Posteriorly –anterior surface of the iliacus and psoas major
Laterally – inner lip of the iliac crest
Medially –vertebral column
Figure 11: Fascia Illiaca Compartment
This compartment contains three of four major nerves ( femoral nerve, lateral cutaeneous nerve of thigh ,obturator nerve ) to the leg. Deposition of local anesthetics in this compartment reliably reaches the femoral & lateral cutaneous nerve only.
Sono Anatomy24 :
By placing high frequency linear usg probe at the level of inguinal ligament identify the femoral artery, femoral vein, lateral and deep to the both vessels there will be a large hypoechoic structure iliopsoas muscle which is covered by thin layer of fascia. This fascia separates the muscle from subcutaneous tissue. Lateral to the femoral artery, between iliopsoas muscle and fascia iliaca there will be a hyperechoic structure which is the femoral nerve. On moving the transducer laterally we will be able to see the Sartorius muscle and its fascia, further movement reveals the anterior superior iliac spine.
Figure 12: Sonoanatomy Of Fascia Iliaca Block
Indications
Perioperative analgesia for fracture neck or shaft of femur
Adjuvant analgesia for hip surgery
Analgesia for above knee amputation
Analgesia for plaster applications in children with femoral fracture
Analgesia for knee surgery along with sciatic nerve block
Contraindications
Patient refusal
Patient on anticoagulations
Infection over injection site
Allergy to local anesthetics
Previous femoral bypass surgery
General Considerations
Fascia iliaca block is simple to perform , alternative to a femoral nerve or lumbar plexus block. The mechanism is that femoral and lateral femoral cutaneous nerves lies under the fascia iliaca. Therefore, local anesthetics deposited beneath the fascia iliaca in a sufficient volume, has the potential to spread underneath the fascia, reach these nerves, even if placed some distance from the nerves. It was thought that the drug could also spread proximally towards the lumbosacral plexus, but this has not been demonstrated consistently.
LANDMARK TECHNIQUE :(Double Pop-up Technique)
A line is drawn between anterior superior iliac spine and pubic tubercle ,
Divide the line into three equal parts . Needle entry point is 1cm caudal from the junction of the lateral and middle third.
Introduce 18G Tuohy needle at an angle of 75 degree with the skin ,can feel two pops as it pierce through fascia lata and fascia iliaca.
Then reduce the angle to 30* and introduce the needle cephalad further 1cm
19G epidural catheter is introduced 15cm beyond the tip of the needle
After negative aspiration, slowly inject local anesthetics aspirating every 5ml.
Success of block with this technique is sporadic hence false pop ups can occur.
Figure 13. Landmarks Of Fascia Iliaca Block
Figure 14: Landmark Technique Of Fascia Iliaca Block
ULTRASOUND GUIDED TECHNIQUE :
The ultrasound guided technique is as same as landmark technique.
However, we can visualize the needle placement and local anesthetics delivery confirms depositions of the drug into the correct plane. Linear transducer high frequency probe (6-14MHz) is used.
Patient in supine position, skin is disinfected with povidone solution.
Place the transducer at the level of femoral crease and oriented parallel to it.
First identify femoral artery, iliopsoas, fascia iliaca and then move the transducer laterally until Sartorius muscle is seen
Make a skin wheel at the point of entry, the needle is inserted “in plane”.
As it passes through the fascia iliaca the fascia is seen indented by the needle, while piercing a pop up is felt and fascia snaps back on the usg image.
To confirm the proper plane (between fascia and iliacus muscle) inject 1- 2 ml of local anaesthetics after negative aspiration .Needle repositioning should be done if the drug spreads above the fascia or with in the substance of muscle.
For a successful blockade 30-40 ml of local anesthetics is required. Drug spread towards the femoral nerve medially & Sartorius muscle laterally.
In obese patients “out of plane” technique is useful.
HOURGLASS PATTERN IN USG25
Place the transducer at Anterior superior illiac spine pointed midway between umbilicus and xiphisternum sliding the probe medially along the inguinal ligament, identify the hourglass pattern which is formed by Sartorius, internal oblique, iliacus muscle. Muscle underlying this hourglass pattern is iliacus & fascia iliaca overlies it. In case of In plane technique insert the needle through the Sartorius muscle till it pierces fascia iliaca where a popup is felt.
After negative aspiration inject 1-2ml of drug/saline which forms a lens of local anesthetics further injection, selfing of muscle from its fascia called as hydro dissection occurs. Drug will spread along the plane as soon as it is injected.
Figure 15: Fascia Iliaca Compartment Block (Needle in Situ)
BUPIVACAINE PHARMACOLOGY
26,27Structure Bupivacaine Hydrochloride is 2-Piperidinecarboxamide, 1-butyl-N-(2,
6-dimethylphenyl)-, monohydrochloride, monohydrate.
Figure 16. Chemical Structure of Bupivacaine
It is an amide local anaesthetic characterized as pipecoloxylidides.
Addition of a butyl group to the piperidine nitrogen of mepivacaine results in bupivacaine. It is a chiral drug , because of possession of asymmetric carbon atom. It is available as racemic mixture, containing equal proportions of the S and R enantiomers.
Its was first synthesized in Sweden by Ekenstam and his colleagues in 1957 and used clinically by L.J. Telivuo in 1963.
Mechanism of action
Local anaesthetics bind to the alpha subunit of voltage gated Na+
channels. It prevents transmission of nerve impulses by inhibiting passage of sodium ions through ion selective sodium channels in nerve membranes.They do not alter the transmembrane potential or threshold potential.
Pharmacokinetics
Its is a weak base that has pKa value above physiologic pH 7.4 . Lung is capable of extracting bupivacaine from circulation. This extraction limits the concentration of drug reaching the sytemic circulation for distribution to the coronary and cerebral circulations. This first pass pulmonary extraction is dose dependent, suggesting that the uptake process becomes saturated rapidly. Alpha 1 glycoprotein is the plasma protein binding site of bupivacaine.
Molecular weight (base) : 288
Pka : 8.1
Protein binding : 95 % Lipid solubility : 28 Volume of distribution : 73 litre
Clearance of drug from plasma : 0.417 lit / min Elimination half life : 210min
Distribution
Three-compartment open model:
* The first compartment is represented by the rapid intravascular distribution of the drug.
* The second compartment represents the equilibration of the drug throughout the highly perfused organs such as the brain, myocardium, lungs, kidneys, and liver.
* The third compartment represents an equilibration of the drug with poorly perfused tissues, such as muscle and fat.
Metabolism and Elimination
After administration in man, peak levels of Bupivacaine in the blood are reached in 30 to 45 minutes, followed by a decline to insignificant levels during the next three to six hours. The half-life of Bupivacaine Hydrochloride in adults is 2.7 hours and in neonates 8.1 hours.
Undergoes varying rate of metabolism by microsomal enzymes located primarily in the liver. Bupivacaine has the slowest metabolism among amide local anaesthetics, it undergoes aromatic hydroxylation, N – dealkylation, amide hydrolysis and conjugation . Only the N – desbutyl bupivacaine has been measured in blood or urine after epidural and spinal anaesthesia. Less then 10% of drug is excreted unchanged in urine. The onset of action after a peripheral nerve block is usually 20-30mins and lasts for 8 to 9 hours.
Preparations and Usage
0.25%, 0.5% in 10ml and 20ml vials- for infiltration , epidural ,peripheral nerve block. Maximum permitted dose 3mg /kg
0.5% bupivacaine + 80mg dextrose in 4ml ampoules– for intrathecal injections. Maximum dose 20mg.
Contraindications
Known hypersensitivity to local anesthetics Intravenous regional anaesthesia
Para cervical block SIDE EFFECTS
The rate of systemic absorption of local anesthetics is dependent
* Upon the total dose injected
* Concentration of drug administered,
* The route of administration,
* The vascularity of the administration site,
Cardiovascular Effects
Bupivacaine is more cardio toxic than equieffective doses of lignocaine.
Accidental intravenous injection of bupivacaine causes severe ventricular arrhythmias and myocardial depression. Bupivacaine blocks cardiac Na +
channels rapidly during systole and dissociates slowly during diastole, so that significant fraction of Na channels remain blocked at the end of the diastole.
Thus the block by Bupivacaine is cumulative and substantially greater. Plasma concentrations of bupivacaine to produce cardiotoxicity is 8-10mic/ml.
IV lipid emulsion has been used in the treatment of cardiotoxicity induced by bupivacaine along with cardio pulmonary resusitation.20% lipid bolus is administrated at a dose of 1.5ml/kg over 1 minute ,can be repeated every 3 to 5 minutes. Followed by infusion of 0.25ml/kg/m. maximum dose of 8ml/kg is recommended.
Central Nervous System Effects
Central nervous system stimulation and depression are produced.
Apparent central stimulation is manifested as restlessness, tremors and shivering progressing to convulsions, followed by depression and coma progressing ultimately to respiratory arrest. A primary depressant effect may occur on the medulla and on higher centers , this may occur without prior excited state.
CNS toxicity is treated by adequate ventilation and oxygenation and by anticonvulsants. Thiopentone (1 to 2ml /kg) may be used in refractory seizures.
MATERIALS AND METHODS
This study was conducted at Government Stanley Medical College hospital, Chennai on 120 patients who underwent elective surgery for femur surgery. This study was conducted after obtaining approval from the institutional ethical committee. Patients were explained about the procedure in detail and informed written consent was obtained for the same.
Study Design
This study is a randomized prospective interventional clinical trial.
Randomization was done by allocating the patients to either the Fascia iliaca group (Group F) or Epidural group (Group E) by draw of lots. Study was a double blinded study. The patients who met the inclusion and exclusion criteria were only included in the study. Patients were divided into 2 groups of 60 each.
Group F : Patients receiving fascia iliaca compartment block ( FICB) Group E : Patients receiving epidural block.
Sample Size
Sample size required for the study
za Zb p1 q1 p2 q2 1.645 0.842 0.78 0.22 0.63 0.37
p1*q1 p2*q2 p2- p1
(p2-p1)^2 p1q1+p2q2 (Za+Zb)^2 Sample size
0.172 0.233 -0.15 0.0225 0.4047 6.1852 111.3
In the published paper reference the success rate observed for epidural procedure is 78% and for FICB catheter procedure is 63%. Based on these proportion for these two groups and assuming the significance level of 5% with power of 80% the required sample size for the study is 112. i.e for each group 56 cases is needed .
Za = Type I error i.e significance level taken as 5% 1- tail test value 1.645 Zb = Type II error i.e Power of the test taken as 80% - value 0.842.
P1 = The proportion of success in Epidural group = 0.78 i.e 78%
q1 = The proportion of failure in Epidural group = 0.22 i.e 22%
P2 = The proportion of success in FICB catheter group = 0.63 i.e 63%
q2 = The proportion of success in FICB catheter group = 0.37 i.e 37%
Sample size = 2(1.645 +0.842)2 (78*22 + 63*37)/ (78-63)2 = 111.3 i.e 112.
Inclusion Criteria
Patients between the ages 18-60 years
Both gender
ASA-PS I, ASA-PS II;
Weight 50-80kg,
Undergoing elective surgery (fracture femur surgery includes neck of femur, total/hemi hip replacement, proximal femur) under spinal anaesthesia.
Exclusion Criteria
Patient refusal
Coagulopathy
Drug allergy
Skin lesions at the side of the blocks
Chronic Pain
Previous femoral bypass surgery Materials Required
Monitor – NIBP ,ECG, Pulse oximeter
Resuscitation equipments and drugs
Antiseptic skin preparation and sterile gloves
Ultrasound machine with high frequency linear probe
17 G epidural tuohy needle set
25 G quinckes spinal needle
Drugs
o inj midazolam , o Inj .bupivacaine 0.5%
o Inj .bupivacaine 0.5% hyperbaric o Inj.tramadol
o Inj. Ondansetron Study Method
Procedure
After approval from the ethical committee and written informed consent, n=120 patient were selected for the study based on the inclusion and exclusion criteria. Written informed consent was obtained from the patient the day before surgery. Using computerized randomized selection, patients were assigned into two groups-Epidural group (group E) and Fascia iliaca group (group F).
On the day of surgery, patients were shifted to pre-medication room started with 18G iv cannula.
Standard Monitors – NIBP, pulse oximeter, ECG are attached. Patient in both groups were premedicated with 0.05 mg/kg of midazolam.
Patients from both the groups underwent fracture femur surgery, under spinal anaesthesia with 3.5 ml 0.5% Bupivacaine(heavy).
Group E patients received epidural catheter at the time of spinal anesthesia preoperatively . Group F patients received fascia iliaca catheter at the end of procedure.
Group E
Patient was placed in sitting position . The back was prepared with povidone solution and sterile drapes applied. 2ml of 2% Lignocaine was used for local infiltration at space L3- L4 space.The approach used for epidural technique was midline approach. Technique chosen for identification of epidural space was loss of resistance technique using a air filled syringe , using the Bromage grip.
18 G Tuohy needle was inserted at L3 –L4 interspace and epidural space is identified at 3.5-5 cm from skin level by LOR Technique. An Epidural catheter was threaded into the epidural space via the epidural needle and catheter was fixed so that 5 cm of the catheter was in epidural space .
After negative aspiration test dose is given with 3ml of 1.5%
Lignocaine with 15microg adrenaline.
Then patients was given spinal anaesthesia with 0.5% hyperbaric Bupivacaine 3.5ml at L4-L5 space using 25G quinckes needle after local infiltration with 2% lignocaine.
Group F
Group F patients were given spinal anesthesia with 3.5 ml of injection 0.5% hyperbaric bupivacaine at L4-L5 interspace using 25G Quinckes needle . At the end of the procedure patient received Ultrasound guided Fascia iliaca compartment block.
Patient was placed in the supine position. After preparation of the skin with povidone solution, a sterile high frequency USG probe(8-12Mhz) is placed at anterior superior iliac spine pointed midway between umbilicus and xiphisternum. Then slide the probe medially along the inguinal ligament to get hourglass pattern.
Then the epidural needle is inserted through the Sartorius muscle in a In Plane approach after a skin wheel is made .Needle entry point was 3-4cm from the edge of the transducer. This allows for a decreased needle angle trajectory to fascial plane ,which optimizes the angle of incidence of the ultrasound beam relative to the needle. Then the needle is advanced until we feel the pops as we pierced fascia iliaca.
Once the needle enters the fascia iliaca compartment, 4-5ml of 0.9%
normal saline is injected to confirm the correct needle placement. Optimal needle location is indicated by the appearance of an anechoeic fluid collection separating the fascia iliaca from iliacus muscle and visibly expands the compartment, usually reached at an average depth of 4-6cm from skin level.
The epidural catheter is introduced 4-6cm beyond the tip of needle into the compartment. The correct location of catheter tip may be confirmed by either direct visualization via usg or local anaethetics accumulation in fascia iliaca compartment. 20 ml of 0.125% bupivacaine injected via the catheter the local anaethetics is injected the fascial compartment expands due to hydrodissection. This will result in separation of fascia from iliacus muscle.
In the recovery room both Group F and Group E was started continuous infusion via catheter at the rate of 8ml/hr for 24 hours .
Outcomes Measured The primary outcome
Assessment of postoperative pain by Visual Analogue scale (VAS score)
Figure 17. Visual Analogue Score
Secondary Outcome measures:
Requirement of rescue analgesia: if the post operative pain score as measures by visual analogue scale is > 3 then rescue analgesia will be given with iv tramadol 100mg
Postop nausea and vomiting :Patients were assessed for nausea by nausea scores
None-0 Mild-1 Moderate-2 Vomiting-3
Rescue antiemetics were given to patients wih nausea score greater then or equal to 2 with inj ondansetron 4mg
Patient Satisfaction:
Patient satisfaction were assessed based on their postoperative analgesia at the end of 24 hours
1 – not satisfying 2 - satisfying 3 – very satisfying
Therapeutic failure is defined as inadequate pain relief from surgical wound and drains.
Technical Failure is the inability to insert catheter as a result of poor tissue planes.
Hypotension was defined as fall in systolic blood pressure to more then 20% of the baseline value.
Bradycardia is defined as decrease in pulse rate to more then 20% of the base line value.
All parameters measured at 1hour ,2,4,8,12,16,and 24 th hour
FLOW CHART OF EVENTS
Written informed consent and explanation of procedure to patient
Patient shifted to premedication room
Monitors connected (NIBP,ecg,SpO2)
18G IV line secured.
Ringer Lactate infusion started
0.05mg/kg Midazolam given for premedication
Patient positioned – sitting position
prepared with Betadine and draped
Epidural space identified by LOR technique and catheter fixed at L3-L4 level in Group E patients. Test dose 1.5% lignocaine with 15µg
adrenaline 1:200000 given.
Spinal anesthesia using 25G Quinckes needle at L4-L5 interspace with 3.5 ml of inj 0.5% bupivacaine heavy injected into subarachnoid space in both groups Intraop vitals monitored.
At the end of surgical procedure in group F patients fascia iliaca block performed using 6-12 MHz usg transducer catheter introduced after confirmation of fascial plane 20ml of 0.125% bupivacaine given and confirmation of drug spread .
Patients from group F received 0.125% bupivacaine 8ml/hr via catheter continuously for 24 hrs
Patients from group E receive 0.125% bupivacaine 8ml/hr via epidural catheter continuously for 24hrs
Primary outcome measured will be numerical rating pain scores/VAS scores on a 0-10 cm scale. Scores measured at 1,4.8,12,16,24 hr after surgery.
Post operative mean arterial pressure ,heart rate monitored at 1,4,8,12,16,24h
Patients will be monitored for side effects of the procedure and also technical / therapeutic failure.
In case of failure(Technical/Therapeutic), rescue analgesia is with injection Tramadol 100 mg IV.
Hypotension will be treated with iv fluids and Inj .ephedrine
In case of bradycardia –inj atropine
Urinary retention –Foley catheter insertion
Nausea vomiting –inj ondansetron
REVIEW OF LITERATURE
1. Diakomion et al 28:
Following hip fractures, positioning the patient for spinal anesthesia is extremely painful. The Author has conducted a prospective randomized comparative study to evaluate the analgesic efficacy of fascia iliaca compartment block (FICB) versus Intra venous fentanyl consumption to position the patient with hip fractures for sub arachnoid block( SAB)
41 patients were included in this study, randomized into two groups . one group received iv fentanyl (1.5mic/kg) 5min before SAB, other group received FICB (40ml of 0.5%Ropivacaine) 20min before the procedure.
Numerical rating pain score before and after placement of analgesia, time needed and quality of position to perform spinal anaesthesia, post operative analgesia in view of time to iv morphine requirement & total dose over 24 hrs and patient satisfaction were studied.
FICB group had lower numerical rating pain score (p<0.001), spinal performance time was shorter (p=0.001), quality of position was better (p=0.001), the time to first dose of morphine demand was longer (p=0.001) &
patient satisfaction was good (p<0.001).
It was concluded from the study that FICB provides superior pain relief when compared to IV fentenyl for positioning the patient for SAB.
2. Gallardo j et al29:
The Author has compared the analgesic efficacy of continuous FICB with continuous epidural in patients posted for knee arthroplasty done under SAB. A sum of 40 patients assessed under ASA PS 1-3 were randomized into two groups .
One group was given SAB plus FICB at a rate of 10ml/hr 0.1%
Bupivacaine. Other group received SAB plus epidural infusion @8ml/hr 0.1%bupivacaine.
Postoperative pain was assessed by Visual Analogue Scale (VAS) at rest and on movement for 24hours. Total IV morphine usage and adverse effects were noted.
Postoperative VAS scores were similar in both groups. In epidural group incidence of arterial hypotension was higher.
3. Capdevila x et al 30:
This study was conducted in 100 adult patients undergoing lower limb surgeries to compare two anterior approaches of Lumbar plexus block namely Three in One (3 in 1) nerve block & fascia iliaca compartment block (FICB)
Effectiveness of technique is analyzed by simultaneous blockade of femoral, obturator, lateral femoral cutaneous nerve & visualization of drug spread by imaging studies.
Both groups were given 30ml of local anesthetic mixture (2%
lignocaine with 1:200,000 adrenaline + 0.5% Bupivacaine) & 5ml of contrast media Ioponidol.
The authors have concluded effective postoperative analgesia provided by both the groups. FICB produces faster and more consistent blockade of both FN & LFCN by means of drug spread under fascia iliaca, rarely to lumbar plexus.
4. Shankes et al31:
In pediatric patients, harvesting graft for post burn reconstructive surgeries is more painful. In this study the author has evaluated the analgesic efficacy of local anaesthetic infiltration versus ultrasound guided single shot LFCN block and continuous catheter placement FICB.
VAS score was monitored for 48 hours. Patients in the regional blocks were more comfortable, that too with continuous catheter experienced more pain relief till second postoperative day.
5. Mcrae pj et al 32:
FICB is the one block simple, easy to learn, effective to give pain relief for femur fracture. Femoral fractures are extremely painful, shifting the patient to the hospital makes the pain worsen. Usually they have been given parenteral opioids for pain relief.
In this study author has examined the feasibility and efficacy of FICB done by paramedics in the prehospital setting. It was a randomized study in which one group received FICB (lidocaine with epinephrine ), other group received iv morphine only. Pain relief was evaluated by 11 point NRS prior and 15 minutes after the procedure. Secondary outcomes such as effectiveness and adverse effects were also noted.
Patients in FICB group had better reduction in their median pain score p-0.025) than control group,and no obvious adverse effects were noted.
It was concluded that paramedics can easily perform FICB for patient with suspected femoral fractures in the prehospital settings.
6. Dolen j et al33:
They have conducted a study to compare the efficacy of fascia iliaca block done by ultrasound guidance versus conventional loss of resistance technique. 80 patients who underwent hip/knee replacement surgery received either ultrasound guided FICB or by conventional method.
Before performing block sensation in the various part of the thigh supplied by femoral nerve, lateral cutaneous nerve of thigh, obturator Nerve were assessed. Motor blockade was assessed by knee extension and hip adduction. Sensory and motor blockade were reassessed after the procedure.
Under usg guidance sensory loss in the medial compartment of thigh increased from 60% to 95% (p=0.001) which was statistically significant.
Complete loss of sensation in all compartment is increased from 47% to 82%.
Incidence of motor blockade observed was femoral (p=0.006) and obturator (p=0.033)
It was concluded from the study that Ultrasound guided FIB is efficient than conventional technique.
7. Tran dq et al34:
Based on EMBASE (jan 1980-april 2007) and MEDLINE (jan 1966- april 2007) database, they summarized evidence regarding techniques and approaches for lower limb nerve block from various randomized controlled trials.
From which they concluded that, in Lumbar plexus block posterior approach (psoas compartment block) is more superior to block obturator nerve than anterior 3 in 1 approach.
FICB is the easiest to perform, and time taken for the procedure is short, cost effective and it can be a better alternative to 3in 1 nerve block.
8. Swenson jd et al35:
In this study the author has examined the pattern of distribution of local anesthetics deposited deep to the fascia iliaca, done at the level of inguinal ligament.
Included ten patients (ASA 1,2) undergoing anterior cruciate ligament reconstruction surgery. These patients received either 3in 1block or FICB under ultrasound guidance.
All three nerves (femoral ,lateral femoral cut nerve & obturator nerve ) were examined for motor and sensory loss. Distribution pattern is examined by subjecting the patient to MRI imaging.
Drug reached upto the level of retroperitonium superiorly, laterally towards anterior superior iliac spine, medially upto femoral vein, not to the obturator nerve.
All patients had sensory loss over anterior, medial, lateral thigh and extensor muscle weakness. But none of the patients showed motor blockade in obturator nerve( hip adduction )
9. Kaloul et al36:
Compared the analgesic efficacy of psoas compartment block with femoral 3in 1 nerve block. Patients undergoing TKR randomly divided into three groups. One group received iv patient controlled morphine analgesia
(PCA) acting as a control, others received PCA + continuous FEM block and PCA+ continuous PSOAS block and both groups were given bolus dose of 0.5%Ropivacaine 30ml with adrenaline and maintenance @ 12ml /hr 0.2%
Ropivacaine for 48hours.
Patients were monitored for VAS score, total morphine consumption, sensory and motor blockade.
Both block groups showed low pain score (p<0.0001) and morphine consumption (FEM 37.3+/-34.7mg p=0.0002 & PSOAS 36.1+/-25.8mg P<0.0001) than PCA(72.2+/-26.6 mg )
Though PSOAS group showed consistant blockade of obturator nerve (p<0.0001) than FEM , there was no difference in pain scores and morphine consumption.
OBSERVATIONS & RESULTS
A randomized controlled double blinded study was conducted to compare the analgesic efficacy of continuous epidural analgesia with ultrasound guided continuous Fascia iliaca compartment block following fracture femur surgery. Sample size selected was 120 patients. The 120 patients were randomly allocated into Group E (epidural) and Group F (fascia iliaca) by computerized randomization. After collecting the data, all the variables are examined for outliers and non-normal distributions. The Categorical variables are expressed as Frequency and Percentage. The Quantity variables are expressed as mean and standard deviation. Descriptive statistics are used to evaluate baseline characteristics.
Student's t-test was used to analyze the parametric data, and discrete (categorical) variables were analyzed using the Chi-Square test, with a P < 0.05 considered statistically significant.
The statistical analysis was carried out using statistical software package SPSS 20.0.
DEMOGRAPHIC PROFILE
Table 3: AGE DISTRIBUTION
AGE IN YEARS GROUP E GROUP F P VALUE Mean ± SD 42.27± 15.5 47.1 ±13.35 0.069
Mean age in group E was 42.27 years and the standard deviation was 15.5 years. Mean age in group F was 47.1 years and the standard deviation was 13.3 These data were computed using students t-test and the P value was found to be 0.069. This difference is considered to be not statistically significant.
Figure 18. AGE DISTRIBUTION
42.27
47.1
20 25 30 35 40 45 50 55 60
GROUP E GROUP F
AGE IN YEARS
GROUP E GROUP F
SEX DISTRIBUTION
The number of male patients in Group F were 42, where as the number of female patients were 18. The number of male patients in Group E were 47, whereas the female patients were 13 in numbers. The data was computed using chi-square test. The two tailed P-value equals 0.297, which is not statistically significant.
Table 4: SEX DISTRIBUTION
SEX GROUP E GROUP F P VALUE
MALE 47 42
0.297
FEMALE 13 18
Figure 19: Sex Distribution
0 5 10 15 20 25 30 35 40 45 50
group E group F
SEX DISTRIBUTION
M F
WEIGHT DISTRIBUTION
Mean weight in Group F was 66 kg with a standard deviation of 7.55kg, m. Mean weight in Group E was 66kg with a standard deviation of 8.52kg. Data was computed using students t-test. The two failed P-value equals 0.821, which is not statistically significant.
Table 5 :WEIGHT DISTRIBUTION
WEIGHT IN KG GROUP E GROUP F P VALUE Mean ± SD 66.48 ± 8.52 66.15 ± 7.55 0.821
Figure 20: Weight Distribution
66.48 66.15
0 10 20 30 40 50 60 70
mean weight in kg
GROUP E GROUP F
